The Impact of United Kingdom and Malaysia's Inherent Health Systems on Their COVID 19 Responses: A Comparison of Containment Strategies
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The Impact of United Kingdom and Malaysia's Inherent
Health Systems on Their COVID‐19 Responses: A
Comparison of Containment Strategies
Shereen Allaham , Isabel‐Cathérine Demel, Intesar Nur, Faizul Nizam Abu
Salim, and Logan Manikam
In March 2020, the outbreak of COVID‐19 was officially declared a global pandemic by the World
Health Organization. Given the novelty of the virus, and hence, lack of official guidance on effective
containment strategies, individual countries opted for different containment approaches ranging from
herd immunity to strict lockdown. The opposing strategies followed by the United Kingdom and its
former colony, Malaysia, stand exemplary for this. Real‐time polymerase chain reaction was im-
plemented for testing in both counties. Malaysia acted with strict quarantining rules and infection
surveillance. The United Kingdom followed an initially lenient, herd‐immunity approach with strict
lockdown only enforced weeks later. Although based on the same health‐care structure historically,
Malaysia developed a more unified health system compared with the United Kingdom. We suggest
that this more centralized structure could be one possible explanation for why Malaysia was able to
react in a more timely and efficient manner, despite its closer geographic proximity to China. We
further explore how the differences in testing and quarantining strategy, as well as political situation
and societal compliance could account for the discrepancy in the United Kingdom's versus Malaysia's
relative success of COVID‐19 containment.
Key Points
1. Different countries employed a range of strategies toward the COVID‐19 pandemic, with
varying levels of success.
2. Malaysia's strict rule enforcement were reflected both in quantitative and qualitative
terms.
3. Despite the closer geographical proximity to the source of the outbreak, Malaysia fared better
than the United Kingdom in its response to the pandemic, suggesting that there are valuable
lessons to be learned for the developed from developing, limited‐resource countries.
KEY WORDS: COVID‐19, community spread, inherent health system, pandemic response, public
health
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This is an open access article under the terms of the Creative Commons Attribution License, which permits use,
distribution and reproduction in any medium, provided the original work is properly cited.
1
doi: 10.1002/wmh3.412
© 2021 The Authors. World Medical & Health Policy published by
Wiley Periodicals LLC on behalf of Policy Studies Organization.2 World Medical & Health Policy
Introduction
The first case of COVID‐19 was officially reported by the Chinese authorities on
December 31, 2019. Three months later, on March 11, 2020, the outbreak was de-
clared a global pandemic by the World Health Organization, 2020c). Given the
novelty of the SARS‐COV2 virus and the unprecedented nature of the situation,
little to no official guidelines were available to advise governments on the most
effective containment strategy. Countries were thus forced to react on a national
and local, rather than global level, some opting for herd immunity with voluntary
social distancing, while others enforced prompt lockdown with intense infection
surveillance.
The varying approaches employed by the United Kingdom and its former
colony, Malaysia, stand exemplary for this: despite similarities in their historic
health‐care structure and recent political situation at the time of the outbreak, the
two countries fared differently during the pandemic. The ultimate success, and
long‐term consequences of their approach, that is, from a social and economic
perspective, remains to be determined (Gibney, 2020).
The aim of this paper is to compare and contrast their containment approaches
by shedding light on factors that facilitated—or hindered—the combatting of the
COVID‐19 pandemic. Using the case study of the United Kingdom versus Ma-
laysia, we explore the role their health systems and organizational structure,
pandemic preparedness, and response, as well as governance and societal com-
pliance, have played in shaping the overall impact of the pandemic on their re-
spective population.
Health Systems—The United Kingdom Versus Malaysia
The United Kingdom funded the National Health Service (NHS) in 1948 with
the primary objective of offering treatment to everyone irrespective of their ability
to pay (Triggle, 2018). The NHS is subdivided into four different countries (Eng-
land, Scotland, Wales, and Northern Ireland) each of which controls the specific
individual and public health‐care policies for that respective area (Boyle, 2011). In
the United Kingdom, different independent organizations are responsible for the
delivery of numerous facets of health care. For example, Public Health England
(PHE) oversees the public health component, while the NHS manages clinical and
health‐related services, and the Department of Health and Social Care (DHSC)
coordinates government policy on health and adult social care matters in England
(National Healthcare Service, 2013).
As a former British colony, Malaysia “inherited” the British health‐care system.
Malaysia, however, has since followed—or maintained—a more unified health‐care
system approach. The country's main provider of health‐care services, the Ministry
of Health (MOH), can effectuate changes from a National to a District level
(Thomas, Beh, & Nordin, 2011 Ministry of Health Malaysia, 2019). The local systemAllaham et al.: Impact of UK and Malaysia's Inherent Health Systems 3
hence remained very centralized at the Federal Government level, with the MOH
asserting control over State Health Department at 13 states and 3 federal territories.
At the federal level, the Director‐General of Health (DG) is assisted by three
deputies namely the Medical Deputy DG (similar to NHS National Medical Di-
rector), Public Health Deputy DG (similar to PHE), and Research and Technical
Support Deputy DG (who oversee six MOH research institutes and the planning
division, mimicking DHSC to a certain extent). Furthermore, Malaysia has both a
public and a private health sector. Rather than paying health‐care‐related services
for everyone, the Malaysian approach prioritizes spending on essential care and
promotes equity by subsidizing treatments those who cannot afford it. This is
associated with a reduction in the government's burden, leading to Malaysia only
allocating around 4.24 percent of GDP on health care—less than half compared
with the United Kingdom (Cooper, 2020; Ministry of Health Malaysia, 2019).
Pandemic Preparedness, COVID‐19 Arrival and Response: The United Kingdom Versus
Malaysia
The first case of COVID‐19 was discovered in the United Kingdom on January
29 (Gallagher, 2020) compared with January 24, 2020, in Malaysia (World Health
Organization, 2020a), where the first surge of COVID‐19 infections likely originated
from a group of Chinese travelers entering the country via Singapore. As an early
preventive measure, a stringent screening process was imposed at all Malaysian
airports given the geographic proximity to the source of the outbreak (Shah
et al., 2020). With this strict approach, the initial wave was contained successfully,
counting only 22 cases over a span of 3 weeks ending February 16, 2020 (World
Health Organization, 2020b). A second case surge was noted on February 27,
overlapping with a religious gathering in Seri Petaling Mosque attended by 16,000
individuals (DG of Health,2020a). This likely had significant consequences on
Malaysia's infection numbers and its overall performance in containing the pan-
demic. Malaysia's first fatal case, reported on March 17, 2020, was also found to be
related to this religious gathering (Shah et al., 2020).
Subsequently, the Malaysian government, in collaboration with the MOH, fo-
cused considerable efforts into containing the outbreak. Participants who had at-
tended the gathering at Seri Petaling Mosque were urged to undergo screening. The
resources available to private and public hospitals were enhanced and local bed
availability for COVID‐19 cases was increased. On March 1, an alliance involving
38 professional medical societies was established with the aim of keeping the population
well‐informed with accurate and up‐to‐date guidance (Shah et al., 2020).
Furthermore, Malaysia instated a Movement Control Order (MCO) on March
18, 2020 after the official classification of COVID‐19 as a global pandemic (New
Straits Times, 2020). This encompassed regulations on international and interstate
traveling, shop operating, schools and universities opening, as well as the can-
cellation of worship services (Shah et al., 2020; World Health Organization, 2020c).
With regards to funding, the MHO set up an action coalition to obtain financial aid4 World Medical & Health Policy
from companies, NGOs, and other organizations to fight the outbreak (Shah
et al., 2020).
Malaysia's rapid response and strict enforcement of rules had imperative value,
especially when accounting for COVID‐19's mode of transmission (respiratory
droplet and direct contact, and consequently, the importance of reducing human‐
to‐human contact in its containment) (Public Health England, 2020).
By contrast, the United Kingdom followed a different, more lenient approach.
Although the PHE mentioned their 5‐year plan to tackle future pandemics in 2019,
specifically referring to the United Kingdom's ability of “Test and Trace” for MERS‐
COV and its successes, the procedure for an outbreak of an unknown disease was
not mentioned (Public Health England, 2019). Similarly, the issue around access to
and availability of personal protective equipment remains untouched upon.
Consequently, the United Kingdom found itself poorly prepared with the
third‐lowest number of hospital beds per 1,000 population among the Group of
20 countries (Organisation for Economic Co‐operation and Development, 2020).
Irrespective of that, the country initially opted for a “herd immunity” approach due
to a concern about the economic and social consequences, for example, loneliness,
isolation, lack of health‐care access, of a strict lockdown situation (Hunter, 2020). A
change in government advice followed on March 16, as cases requiring ICU ad-
mission started exceeding the NHS’ capacities: Symptomatic individuals and their
close household contacts were advised to self‐isolate for 7 days, with anyone over
70 to avoid any “non‐essential social contact” (Hunter, 2020). Mass gatherings were
discouraged, but not banned. The hard lockdown was enforced on March 23, 2020.
By this time, 6,650 people had been confirmed positive for the disease with 335
fatalities (Rawlinson, 2020) compared to only 2 deaths and 673 cases in Malaysia on
March 17 (DG of Health, 2020b). Thorough preparation, a timely and stricter re-
sponse, as well as consistent government advice would likely have lessened United
Kingdom infections and deaths.
Approach to “Test and Trace”: The United Kingdom Versus Malaysia
What both countries share is that real‐time reverse‐transcription polymerase
chain reaction (RT‐PCR) (Watson, Whiting, & Brush, 2020) was employed in the
detection and diagnosis of COVID‐19 infected individuals. Although this is the
WHO‐recommended gold standard, RT‐PCR requires big laboratories, hence being
subject to limitations in scalability and time. Consequently, testing capacities were
limited at the initial stages in both countries. In the United Kingdom, testing
commenced at a capacity of only 5,000 a day, rendering it almost impossible to
make accurate estimations on national infection numbers in the early stages of the
outbreak (Department of Health and Social Care, 2020). Malaysia had a testing
capacity of 11,500 at the same point in time—a number more than double that of the
United Kingdom (Murugesan & Harun, 2020). Interestingly, the Institute for
Medical Research, MOH had already started studying and designing primers and
probes specific for COVID‐19 detection on March 11 based on the geneticAllaham et al.: Impact of UK and Malaysia's Inherent Health Systems 5
information of the virus China had shared with the world. This was even before
WHO published a similar protocol on March 17 (DG of Health, 2020c).
The approach toward “Testing and Tracing,” however, varied greatly between both
countries. Although real‐time RT‐PCR is a very specific test (test specificity 95 percent), it
is reported to have a relatively high false‐negative rate, that is, a significant probability of
having COVID‐19 despite being tested negative (Watson et al., 2020). Furthermore, due
to the test's high sensitivity, patients who are no longer infectious, yet have not fully
cleared the virus, are frequently misdiagnosed as positive, given the presence of rem-
nants of viral RNA in their system. This, overall, creates a logistic problem where a
negative test result may indeed be positive and vice versa.
Again, both countries responded differently to this challenge: in Malaysia, all
individuals who tested positive were admitted to hospital for observation and/or
early treatment irrespective of symptom strength. Even the asymptomatic were
hospitalized for monitoring purposes (NADMA Malaysia, 2020). Those who tested
negative, but showed symptoms were classified as “Persons under Surveillance”
based on clinical suspicion with compulsory quarantine for 14 days, either at home
or approved quarantine station. RT‐PCR was repeated on Day 13.
Unlike Malaysia, the United Kingdom implemented “at home isolation”—a strategy
that may be cost‐effective but came with the trade‐off that numerous infected in-
dividuals got significantly worse before intervention was offered (National Health
Service, 2020). This is particularly problematic in cases where coronavirus is known to
have a worse outcome (Office for National Statistics, 2019), namely in the elderly and
those with pre‐existing medical conditions. This is a pertinent point, especially when
considering the two countries’ respective population demographics: England has a more
elderly population with 18 percent over the age of 65 (Office for National Statistics, 2019)
compared with 6.9 percent in Malaysia (Razak, 2020). Had the United Kingdom adopted
the aggressive Malaysian style of test, trace, isolate and treat, it would have likely
reduced mortality rates, especially among the elderly who could have received earlier
intervention. Since then, the United Kingdom has focused its efforts on scaling up its
testing capacity: the country is currently performing 450.48 COVID‐19 tests/1,000 people
per day compared with 69.16 COVID‐19 tests/1,000 people in Malaysia (data accurate as
of November 9, 2020) (Our World in Data, 2020). Furthermore, early preventive meas-
ures have recently been announced by the U.K. government to prevent, or at least limit
the severity, of a second wave. These encompass tight regulations on social gatherings,
for example, a maximum of 15 guests attending weddings and funerals, and restrictions
on the opening hours for cafes, restaurants, and bars. Measures will be effective from
September 24, likely lasting for a period of 6 months (BBC News, 2020). The United
Kingdom has further recently introduced a three‐tier system, classifying regions within
the country with an ample system according to the number of infected individual in the
region in question, that is, green/Tier 1 = low risk, yellow/Tier 2 = intermediate risk,
red/Tier 3 = high risk. This allows restrictions and lockdown measures to be im-
plemented at a local and regional, rather than national level. In terms of who to test, the
NHS continues offering free testing merely to symptomatic individuals and their close
household contacts. Asymptomatic individuals can request COVID‐19 testing only
against a fee in the private sector (gov.uk, 2020). In contrast, Malaysia has opted for6 World Medical & Health Policy
“open public testing” including the asymptomatic, through “drive‐through testing” and
other facilities. Comprehensive contact tracing of all confirmed cases is conducted in
both counties (Our World in Data, 2020).
Governance and Societal Compliance: The United Kingdom Versus Malaysia
Governance and coordination are crucial to any country, even more so in
critical situations like the COVID‐19 pandemic. Both the United Kingdom and
Malaysia were experiencing political issues at or close to the time of the outbreak.
The United Kingdom, in light of discussions around Brexit, had recently had three
Prime Minister changes from 2015 to 2020 (Edginton, 2020). This political instability
may have resulted in insecurity amongst the population, leaving many appre-
hensive and distrustful toward the government. These factors may be inherently
linked to societal compliance. Furthermore, the U.K. government has less power
over health care since the Health and Social Care Act 2012, meaning it cannot enact
quick changes to public health (The Kings Fund, 2017). Given the lack of a hier-
archical system, the minister is unable to effectuate changes without prior au-
thorization from other sectors. Although this is a sensible approach in general, it
can result in a significant slow‐down of the decision making in situations where
timely reactions are of the essence, like in the recent pandemic.
The Malaysian government was also facing issues as Prime Minister, Mahathir bin
Mohamad, stepped down on February 24 (Ratcliffe, 2020). Following his resignation, the
country found itself in a precarious situation: without a Prime Minister and functioning
Cabinet, Malaysia was unable to activate the “Disease Control Act” (Act 342) for its
lockdown endeavors. There was, however, a quick succession through political party
realignment in the House of Representatives on March 1, 2020, leading to a new coalition
governing Malaysia. Despite some opposing voices in the public, implementation was
swift, involving a democratic process in alignment with the Malaysian constitution.
Once the Prime Minister and Cabinet were in power, the “Disease Control Act” was
successfully instated and decisions were made promptly. The National Security Council
took charge of non‐health matters, while MOH was given full authority over health
matters. This clear division of roles allowed for quicker implementation of public health
reforms and inspired confidence in the government by the Malaysian people, and also
among those initially opposing the new government. Furthermore, the central control of
MOH/DG of Health over the three big functions held by the Deputy DGs and the
13 states/3 federal territories facilitated the decision making and crisis response. Unlike
in the United Kingdom, many technical decisions could be made by the technocrat chief,
for example, the Director‐General of Health in central committee meetings, allowing for
a prompt translation into public health actions on the ground (at the district level), labs,
clinics, and hospitals. A combination of these factors likely contributed to reducing the
spread of COVID‐19.
A study of public views carried out by King's College London found that
9 percent of the U.K. population were resisting the quarantine (Duffy &
Allington, 2020). Given the recent political uncertainty, this dark figure, however,
may be much higher. In Malaysia, on the other hand, people's behavior changedAllaham et al.: Impact of UK and Malaysia's Inherent Health Systems 7
even before the implementation of the MCO. People started social distancing (83.4
percent) and trusted the government (89.9 percent) (Azlan, Hamzah, Sern, Ayub, &
Mohamad, 2020).
Conclusion
The United Kingdom‘s response to Coronavirus led to 62.64 COVID‐19 deaths
per million people compared to 1.79 deaths per million in Malaysia (data accurate
as of November 9) (gov.uk, 2020; Our World in Data, 2020). Although multiple
reasons contributed to this large disparity, it also suggests issues related to a lack of
public health intervention or timeliness of its intervention. The United Kingdom,
despite being more developed and economically advanced than Malaysia, fared
worse in the COVID‐19 pandemic. The late response, the greater population den-
sity in the United Kingdom, the lack of testing capacity, and societal compliance at
the beginning of the pandemic contributed to a substantial number of infections
and fatalities. Despite having a well‐differentiated, mature health system, the U.K.
failed to respond sooner to the WHO's warning, the country's deaths, and con-
firmed cases. Political uncertainty and inherent features of the country's health
system may have contributed to this. Malaysia, by contrast, acted sooner, em-
ploying strict, effective measures. Consequently, the Malaysian population largely
trusted their government and the MOH, changing their behavior to align with the
new rules. Lockdown implemented at the right time, strong public health prowess
of MOH at the federal level, all the way to state and local districts, seemed to have
made the difference, setting Malaysia apart from the United Kingdom, despite its
geographic proximity to the origin of the outbreak—China.
In recent weeks and months, however, it seems the United Kingdom has at-
tempted to learn from its past mistakes, employing early preventive measures for
the impending second wave. Nevertheless, national‐level reviews will be required
during the years to come to understand how the United Kingdom's capabilities
were squandered.
Undoubtedly, there are areas for improvement for both countries. It does,
however, appear that the British could learn from its former colony on how to
deliver better preventive public health for its people. The three main lessons
learned from the COVID‐19 pandemic include the importance of
(i) acting early and allocating enough time to prepare the health‐care system,
(ii) minimizing infection numbers, and
(iii) empowerment of and trust from the public.
Note
Logan Manikam and Shereen Allaham are funded via a National Institute for
Health Research (NIHR) Advanced Fellowship (Ref: NIHR300020) to undertake the
feasibility randomised controlled trial of the NEON study in East London.
Corresponding author: Shereen Allaham, s.laham@ucl.ac.uk8 World Medical & Health Policy
Shereen Allaham is a research associate at the University College London Institute
of Epidemiology and Health Care in London, UK, and a consultant at Aceso Global
Health Consultants in London, UK.
Isabel‐Catherine Demel is a medical student at Kings College's GKT School of
Medical Education in London, UK, and an honorary research associate at Aceso
Global Health Consultants in London, UK.
Intesar Nur is a medical student at the University of Birmingham in
Birmingham, UK.
Faizul Nizam Abu Salim is a Ph.D. candidate at the National University of
Malaysia in Kuala Lumpur, Malaysia, and clinical administrator at the Ministry of
Health in Putrajaya, Malaysia.
Logan Manikam is an NIHR advance fellow and consultant of Public Health
Medicine at the University College London Institute of Epidemiology and Health
Care in London, UK, and Director at Aceso Global Health Consultants in
London, UK.
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